Patient is a 21 year old female in junior year of college. She has no chronic medical conditions and takes no medications on a regular basis. Her only surgical history is tonsillectomy as a toddler. She is being seen today for complaints of "acne." She was seen previously at her campus health center and was given a script for t-stat pads (erythromycin topical), which she has been using for two weeks and feels her condition has only worsened. She has also tried over the counter benzoyl peroxide face washes BID without aid. It is now winter break and she is home for three weeks from college. She states she feels tired following a busy exam week, but otherwise feels well. She would like her acne resolved before returning to campus!
Vital signs are normal. BMI 24 with a 5 pound weight loss noted since last visit 1 year ago. She attributes that to making healthier choices in campus dining. Physical exam is notable for scattered pustules ranging in size from 1-2cm across cheeks, forehead, chin, and shoulders. Some are erythemic, some white. Some have scabs, others are intact and fluid filled. None are actively draining.
What at should be the next steps for this patient?
Sarcoidosis can involve most organ systems via granulomas and lymph nodes. Lungs are the most commonly recognized system but the disease can effect the whole body.
Inflammatory and and autoimmune response essentially.
Haven't read too many answers...just a few yesterday... but this seems like it could be several things. I could take a stab at an allergy of some kind. Dermatology and allergy consult.
OOPS...see you added bruising in a later addition of s/s. hmm. Interesting. Maybe more than one thing going on too.
Because someone is immune to the chicken pox virus doesn't mean they can't get shingles. Plus, at 21 I would assume she received the chicken pox vaccine, which again doesn't mean that one can not get chicken pox, in my understanding.
Good thought. I actually saw this patient years ago and she was 21 at that time.
She likely has some type of acute leukemia (high white count, low platelets, high blast percentage) with tumor lysis, indicated by the high uric acid, hyperkalemia, and high LDH.
Ding ding ding. As soon as these results came in, she was admitted to the heme/onc service. Leukophoresis was preformed and PRBC and platelet transfusions were given. A bone marrow biopsy was then preformed, which confirmed a diagnosis of AML.
Leukemia cutis is a rare dermatological manifestation of leukemia. It's leukemic infiltrates in the skin. It can present in a variety of ways. This patient's initial presentation looked remarkably like simple acne and likely any clinician would have diagnosed it as that.
Leukemia cutis can be seen with any type of leukemia, but is most common with AML M5, effecting 30-50% of patients with that sub type. It's rare for leukemia cutis to be the initial symptom, only prestaging more classic, systemic, symptoms in about 7% of patients.
This patient received induction with 7+3 chemo (Cytarabine and Daunarubocin). She nadirred as expected, had her course complicated by culture neutropenic fever and was discharged upon count recovery. Her cytogenetic were consistent with high risk disease, so her brother was HLA screened and found to be a match and she underwent allo sib stem cell transplant and has maintained remission since.
Points to consider:
This diagnosis would likely have been missed regardless of who had seen the patient the first few visits, however, a full review of systems should be done at every office visit to assess overall health and pick up on subtle symptoms, particularly in patient populations that may easily write off vague symptoms.
A full skin exam is always of value for any dermatological complaint.
Patients should always know that follow up time frames are open ended and feel free to call if symptoms worsen. If this patient hadn't done that, her disease may have gone undiagnosed longer.
When hearing hooves, it does make sense to think horses, but sometimes it is the zebra. When in doubt, some simple blood work can be revealing sometimes.
Specializes in Nurse Leader specializing in Labor & Delivery.
THat was awesome, thank you Blondy!
That was a lot of fun (normally I wouldn't say that regarding a leukemia dx, but you said this took place many years ago), and something I hope to see more of around here!
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Sarcoidosis can involve most organ systems via granulomas and lymph nodes. Lungs are the most commonly recognized system but the disease can effect the whole body.
Inflammatory and and autoimmune response essentially.